SoonerCare Health Management Program

OHCA launched an innovative and comprehensive health management program in February 2008. The SoonerCare Health Management Program (HMP) benefits both SoonerCare members who have chronic conditions and their SoonerCare Choice primary care providers. SoonerCare members at highest risk for adverse outcomes and increased health expenditures receive intervention and ongoing assistance from a nurse care manager. Providers are offered the services of a practice facilitator to enhance quality and efficiency through use of evidence-based best practices and provider education conferences and collaboratives.

Members are selected for the program using predictive modeling software that identifies those who are at high risk for adverse outcomes and increased health care expenditures. Most of this risk is driven by co-morbid conditions that increase the likelihood of a health care crisis. Members identified to be at very high risk (Tier 1) receive face-to-face intervention by a nurse care manager (NCM). Members identified to be at high risk (Tier 2) receive nurse care management by telephone. NCMs provide education and support specific to their conditions, help coordinate care and improve self-management skills. They also provide feedback to the member’s primary care provider.

Primary care providers receive mailings containing disease-specific, evidence-based guidelines, state and regional collaboratives (with CME and CEU credits available), and the opportunity to participate in a practice facilitation program. A full-time medical professional specifically trained in practice facilitation is deployed to participating practices for a period of one to two months to help them implement quality improvement techniques, design an office system to improve efficiency and implement a clinical disease registry that may be used for the entire patient population of the practice. Participating practices may be eligible for financial incentives. 

Expanding coverage through private sector initiatives

Insure Oklahoma

Insure Oklahoma (Oklahoma Employer/employee Partnership for Insurance Coverage) Employer-Sponsored Insurance is designed to assist owners of small businesses, employees and their spouses with health insurance premiums. Funds from the state’s tobacco tax are used to pay 60 percent of the premiums for policies offered through qualified health plans. The employer pays 25 percent, and the employee the remaining 15 percent. The program is currently available to companies with 50 or fewer employees. The employees also must meet income standards (200 percent FPL) to qualify for the program. As of July 2008, 9,349 employees and their spouses were taking part, representing 2,969 businesses. In 2007, the Oklahoma Legislature expanded the program to companies with up to 250 employees and workers earning up to 250 percent of the FPL. The expansion is on hold pending approval from the Centers for Medicare & Medicaid Services.

Insure Oklahoma/O-EPIC also offers an Individual Plan that allows people who can’t access the program through their employer, including those who are self-employed or may be temporarily unemployed, to buy health insurance directly through the state. Individuals can buy into a state-sponsored health plan if they meet income standards (200 percent FPL). Premiums are based on a sliding scale depending on the person’s income. This program also is funded through Oklahoma’s tobacco tax. In July 2008, 3,299 individuals were enrolled in that plan.

Oklahoma Long-Term Care Partnership Project

In July 2008, Oklahoma launched its Long-Term Care Partnership Expansion Project, an effort that will help develop practical long-term care insurance options for consumers. Oklahoma is working with private insurers to create affordable long-term care insurance options that protect consumer assets and minimize budget risks to SoonerCare (the state’s Medicaid program). SoonerCare funds about 73 percent of all nursing home care in the state. Many elderly Oklahomans have been faced with “spending down” their assets in order to qualify for SoonerCare. This project would allow them to protect assets equal to the value of their long-term care insurance policies.

Transparent and publicly accessible measurements of patient outcomes and/or quality improvements

Quality-based nursing facility reimbursement system

Oklahoma’s Medicaid Reform Act of 2006 authorized the Oklahoma Health Care Authority to begin its “Focus on Excellence” program, an incentive-based rate plan for nursing facilities. The program is designed to measure improvements in the quality of life, care and services. A set of 10 performance data components are measured to reward demonstrated value, support evidence-based quality improvement by nursing homes, and furnish consumers with frequently updated information to use in comparing and choosing nursing homes. Facilities that meet higher standards can earn bonus payments, and the information collected by a contracted health care data management firm can be used by the facilities to set and meet performance improvement targets. Oklahoma is the first state to take on this type of quality initiative.

A consumer component of the “Focus on Excellence” program debuted in April 2008.  OHCA launched a new Web site, www.oknursinghomeratings.com, to provide current information about Oklahoma nursing facilities. The site is intended to help consumers make wiser choices when choosing long-term care facilities. It provides information on 10 performance categories such as quality of care; employee, resident and family satisfaction; and compliance with state and federal requirements. Nursing facilities are also able to post additional information, such as special services, activities or therapies they offer, to the site. A quick search option allows consumers to search by city, zip code or rating factor criteria.

Efforts to combat fraud and abuse

Emergency Room Utilization

The Oklahoma Health Care Authority’s emergency room utilization intervention program has helped to significantly reduce inappropriate use of hospital facilities.

In the past several years, the OHCA has identified 13,736 members responsible for 81,384 emergency room visits. Members are flagged if they have visited the E.R. more than four times during one calendar quarter. These members receive letters and phone calls reminding them of the benefits of seeing their primary care physician for non-emergency care and reminding them who their primary care physician is. (The physician is also notified of the intervention activities.) Exceptionally heavy E.R. users may receive face-to-face interviews.

It is estimated that intervention efforts with these members has resulted in 19,260 fewer ER visits. For state fiscal year 2007 alone, that equates to about $5.8 million in avoided ER costs.

What changes would you make to the federal Title XIX so that you could provide better services to individuals and families on Medicaid in your state?

First, we believe that it is crucial that Title XIX be totally delinked from its historic connection to the welfare program. That ongoing connection is a major roadblock toward providing health insurance coverage to single adults, despite their level of need. All required categorical relationships should be repealed for the purposes of health coverage.

We also feel strongly that all provisions of Title XIX that are now subject to federal waivers also should be repealed in favor of giving states the flexibility to develop programs appropriate for their specific needs – including the use of federal financial resources to subsidize the purchase of private health insurance. Giving states greater discretion in effective use of federal funds would allow us to better tailor programs to meet the needs of all members and enhance ways of instilling member responsibility.

What are your future plans?

“Medical Home” Model of Care

After lengthy discussions with an advisory task force of physicians, the Oklahoma Health Care Authority is moving toward a “medical home” model of care. While the changes will be largely unnoticed by SoonerCare members, it will make significant changes in the reimbursement structure for providers.

Some providers felt the current rate structure, in which providers are paid a bundled monthly fee for their entire panel of SoonerCare members, whether they were seen or not, was inequitable. They felt some providers drew sizeable monthly payments for large panels of SoonerCare members whom they rarely saw, while others had fewer SoonerCare patients who required considerably more time and attention yet drew the same reimbursement.

The medical home structure will pay providers a monthly case management fee that is smaller than the current capitation rate, but providers will also be reimbursed through a fee-for-service plan. The new payment structure will include a tiered performance-based component that will allow providers to draw a higher per-member-per-month rate by providing additional services, such as using e-prescribing, adopting evidence-based guidelines on preventive and chronic care, and adopting a more flexible scheduling process. Providers also will receive quarterly “SoonerExcel” payments for child health exams, generic drug prescribing, screening for breast and cervical cancer and visits to patients in the hospital.

OHCA expects to change to the medical home model in early 2009 and to offer transitional payments to providers to help them adjust during the first year.

Living Choice

The Oklahoma Health Care Authority, in partnership with Progressive Independence, the Oklahoma Long-Term Care Authority, the Oklahoma Department of Human Services, community organizations and stakeholders, is currently working to design the Oklahoma Long-Term Living Choice Project.

Over five years, a grant of $50 million will allow Living Choice members to receive care in an appropriate home or community setting rather than remain in a nursing facility. The program will identify barriers to community living and provide support, such as home health and residence modifications, to help with the transition.

Covering the Uninsured

Oklahoma’s Legislature has approved the “All Kids Act,” which will help purchase health insurance for children in families with incomes between 185 percent and 300 percent of the federal poverty level.

In a letter to Oklahoma Medicaid officials, the Centers for Medicare &  Medicaid Services (CMS) issued a new directive. This directive required, among other things, that states achieve a participation rate of 95 percent among children living in families with income under 200 percent of federal poverty level (FPL) as a prerequisite for using State Children’s Health Insurance Program (SCHIP) funds to cover children with family incomes above 250 percent of the FPL.

In response, OHCA amended its waiver request and is now applying to bring the level up to 250 percent of the federal poverty level instead of the full 300 percent. Oklahoma will apply for an additional waiver to bring the income eligibility up to 300 percent after the state meets the more stringent requirements set by the federal government for further expansion. It is estimated that Oklahoma has about an 86 percent participation rate in the current program.

OHCA is also working at expanding its options through the Insure Oklahoma programs to offer premium assistance to additional groups of uninsured adults.